Safety Messages

Lessons From Challenger

 

This Jan. 28, marks the 35th anniversary of the Challenger accident. The loss of the crew was a tragedy felt by their families, friends and coworkers at the agency, as well as people throughout the world.

The Challenger accident taught us tough lessons and brought forward what have become recognizable phrases: normalization of deviance, organizational silence and silent safety program. Sadly, we learned these lessons again in 2003 with the loss of Columbia and her crew. This shows how vital it is that we pause to revisit these lessons and never let them be forgotten. We cannot become complacent. 

In this month's Safety Message, Harmony Myers, director of the NASA Safety Center, discusses the Challenger accident and the lessons it continues to teach us today.

Reminders to Keep You Safe

Welcome to the Office of Safety and Mission Assurance Safety Message archive. This page contains Safety Message presentations and related media. While some of these presentations are not NASA related, all of them have certain aspects that are applicable to NASA. I encourage you to disseminate these to your organizations to promote discussion of these issues and possible solutions.

—W. Russ DeLoach, Chief, Safety and Mission Assurance

Atlas Centaur (AC-67)

Lightning Strike Mishap 1987

March 01, 2007

On March 26, 1987, NASA launched Atlas/Centaur AC-67 from the Eastern Test Range. The vehicle triggered lightning 49 seconds after launch resulting in GN&C failure and structural breakup. Both launch vehicle and Navy communication satellite were lost.

Safety Critical Software Control Errors

Radiation Cancer Therapy Machine Mishaps

December 01, 2006

In a 20-month period between June 1985 and January 1987, Therac-25 radiation therapy machines used in both the U.S. and Canada administered massive overdoses of electron beam radiation to at least six cancer patients, with at least three deaths attributed to radiation overdose.

Mishap at an Explosives R&D Laboratory

ATK Thiokol Explosives Lab

October 01, 2006

At 10:45 p.m. on Feb. 14, 2005, a explosion and fire occurred in the R&D laboratory building M-590 at the ATK Thiokol Promontory campus. Two laboratory technicians were transferring a chemical compound known as TETNB from a filter tray into 5-gallon plastic buckets. One of the technicians was killed, the other severely burned.

Ames Arc Jet DC Power Supply Fire

Ames Arc Jet DC Power Supply Fire

September 01, 2006

During Arc Jet operations a DC Power Supply Module was discovered burning Internal components were severely damaged Classified Type C mishap ($25,000 to $250,000 property damage) There were no injuries to personnel.

Davis-Besse Close Call

Davis-Besse Power Plant

September 01, 2006

On Feb. 16, 2002, Davis-Besse (Oak Harbor, Ohio) nuclear plant personnel were repairing cracks in the vessel head penetration (VHP) nozzles. While being machined, the nozzles which were supposed to be embedded tipped over. Further inspection identified a large penetrated cavity of 20 to 30 square inches. The cavity penetrated completely through the 6.63 inches of carbon steel to the thin stainless steel cladding liner. The liner (0.38 inch) was all that was preventing a large loss of coolant accident with potential catastrophic consequences.

Air Force Atlas Mishap

Unintended Mixing Lox and Hydrocarbons (1975)

August 01, 2006

On April 12, 1975, an Atlas 71F vehicle suffered extensive engine damage due to an explosion at liftoff at Vandenberg Air Force Base. Range Safety destroyed vehicle at 303 seconds.

Submarine Down

USS Thresher Lessons Learned

June 01, 2006

The USS Thresher was launched in 1960. The first ship of her class (nuclear powered attack), the leading edge of U.S. submarine technology, she was fast, quiet and deep-diving. On April 10, 1963, while engaged in a deep test dive 220 miles east of Cape Cod, Massachusetts, the USS Thresher, SSN 593, was lost at sea settling at a depth of 8,400 feet with all aboard. The crew of 112 Naval Officers and Enlisted personnel and 17 civilians died.

Are We Prepared?

Hurricane Season

May 01, 2006

2005 set the record with 28 named storms — 15 became full hurricanes and four major hurricanes hit the U.S. Katrina set the record for the costliest, with $80 billion in damage and for the deadliest, with over 1,300 people killed. However, Katrina was only the sixth strongest hurricane on record. The 2006 hurricane season begins June 1.  The National Oceanic and Atmospheric Administration
predicts 2006 to remain well above normal activity.

A Gift

Lessons from the STS-3 Close Call

May 01, 2006

Touchdown was 25 kts. too fast (220 kts vs. 195 kts EAS). CDR started nose down prematurely, then realizing error, immediately applied aft stick to stop nose down pitch. CDR needed excessive aft stick to stop nose, then was surprised by pitch rate reversal (pitch gain glitch). Second pitch reversal resulted in higher than desired nose gear slap down. Close call: nothing broken, nobody injured, but STS-3 came close to being two flights.

Fatal Mishap in Pressure System Operation

Pressure System Operation in a Government Lab

April 01, 2006

Early 2006, a pressure system failed during initial use in a government laboratory. One worker was killed, creating significant programmatic disruptions and possible personal legal consequences.

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